SEFARI fellowship: the older population and foodborne illness

As outlined in section 3.6, the Health Belief Model suggests that health behaviours are influenced by the “perceptions of severity” and “personal susceptibility”, combined with perceived benefits and barriers to that behaviour (Rosenstock, 1974). More recent adaptations of the model, include “cue to action,” which refers to a stimulus to undertake the behaviour; and “self-efficacy”, which is confidence in one's ability to perform the behaviour (Etheridge et al., 2023). Furthermore, it is suggested that the modifying variables within the Health Belief Model, may facilitate or hinder health actions (Cronin et al., 2018) as modifying factors can influence individual perceptions and the perceived benefits. For the purpose of this study, five determinants were selected as the modifying variables.

Numerous studies have demonstrated how perceptions within the Health Belief Model influence action, however for the purpose of this study it is believed to be imperative to understand the background that can influence such perceptions, the findings are discussed in the context of the model as outlined in Figure 1.

Modifying factors are factors that enable an individual to engage in health behaviour. They are prerequisites for converting health attitudes into health behaviours (Kalua & Nyasulu, 2007), modifying variables within the Health Belief Model, may facilitate or hinder health actions (Cronin et al., 2018). 

This section explores determinants that are seldom considered in consumer food safety research. As discussed in section 5.1 and presented in Table 2, five determinants were deemed appropriate for this study, namely physical, biological, social, psychological and economical. These determinants may hold important findings indicating why certain perceptions are held by consumers in relation to foodborne illness that may prevent food safety behaviours from being implemented. Such findings may be beneficial for targeting future food safety communication campaigns or provide insight to why food safety messaging may be disregarded. Although the variables are presented separately, they are often interlinked, as described by Participant 029:

The World Health Organisation states that the physical environment can impact upon people’s health, examples of which include having safe water and clean air, healthy workplaces, safe houses, communities, employment and working conditions (World Health Organization, 2017). The themes relating to the physical environment in this study related to time after employment/retirement for food related activities, access or distance to shops and supermarkets, and access to private or public transport. A summary of related quotes are presented in Table 3.

Many reported having time after retirement for food related activities and described changes in cooking and eating habits after retirement and the impact of increased free time on their diet. Participants describe having more time after retirement to focus on meal planning, healthier eating, and careful food preparation. One participant emphasised how this change has improved their diabetes management and allowed for a more mindful diet, while others described increased snacking due to boredom in retirement and having fewer activities to occupy their day. In general, many felt their diets had improved following retirement. 

One participant discussed how they took over cooking responsibilities when they retired, and their spouse continued working. Though new to cooking, they enjoy the process and learning from mistakes, unlike their spouse, who grew tired of cooking after decades of doing it for the family. However, another participant mentioned that while they have more time, their lack of enjoyment in cooking and shopping remains unchanged. 

Access and proximity to shops was widely discussed and given that individuals had been recruited from across Scotland, there were diverse experiences related to shopping, particularly in rural and semi-rural areas in comparison to those living in urban areas. Many emphasised the challenges of living far from supermarkets, often having to make long car journeys, and planning these for once a week. Others relied upon online deliveries or local services such as fish vans. Others discussed the use of local shops for top-up purchases, although these can be more expensive and offer limited variety. Some prefer supporting local butchers and bakers, valuing quality and freshness, despite acknowledging the convenience of larger supermarkets. 

COVID-19 also influenced shopping habits, prompting a shift toward local shopping and home deliveries. Overall, shopping habits are shaped by factors like accessibility, costs, mobility, and the desire to support local businesses where possible, while also relying on larger supermarkets for variety and affordability. Discussions also related to the lack of choice and having a limited diet because of the availability of food in local rural shops.

Those reliant on online food deliveries discussed reoccurring problems, other described that the issues prevented them from using online food deliveries. Many participants expressed frustration with the inability to select their own items, particularly fresh produce, receiving products with short shelf-life, as well as concerns about substitutions:

"I would never trust someone else to pick out my fresh stuff." (Participant 8).

"Sometimes they’ll substitute items, but it’s not always something you would choose yourself." (Participant 15).

"I just feel that they’ll be sending stuff that is out of date or nearly out of date." (Participant 22).

Some described overcoming these challenges by not purchasing fresh produce, and buying these locally, or having to freeze items that are about to pass the use-by date.

The discussions highlighted some of the challenges faced by individuals, particularly those living in rural areas or with limited mobility when it comes to grocery shopping. Many participants rely on cars to maintain their independence and access supermarkets, but the rising cost of fuel and concerns about health-related driving limitations are common. Public transportation was often described as being inadequate, especially for those in rural areas, leading to isolation or reliance on others for help. Sometimes the practicalities of taking shopping bags on the bus was not feasible. There is also a sense of frustration in losing control over one's shopping decisions due to mobility or transportation issues. 

Some acknowledged that it would be challenging to go shopping if they didn’t have a car or were unable to drive, however many did not think about what they would do if they reached a stage that they were no longer able to drive, whereas other were concerned and planning. Some participants suggested that they would utilise online grocery shopping services but were mindful that this wouldn’t replace the experience of in-person shopping. In general, participants didn’t want to think about being in that situation.

Numerous studies have previously discussed food deserts and the impact of location upon access to healthy food and nutritional deficiency (Cummins et al., 2010; Janatabadi et al., 2024; Jin & Lu, 2021; Wrigley, 2002), however the impact of the physical environment upon the food safety context has not previously been considered, however it may be suggested that for some that are reliant on doing a once-weekly shop or utilising online grocery deliveries may subject food to prolonged storage in the domestic kitchen, for this safe refrigeration temperatures are critical, and for those that are freezing foods, appropriate thawing and usage are essential.

Numerous biological determinants were discussed during the online and in-person discussion groups. However, more challenges were discussed by those individuals that were responsible for supporting their relatives with food related tasks. Biological determinants included health conditions and concerns associated with increasing age, the impact of mobility on food habits, changes in appetite and ability to eat, other sensory factors such as eye-sight and sense of smell and taste were also discussed. Some relevant quotes are presented in Table 4.

The participants discussed how various age-related health conditions, such as diabetes, high cholesterol, and cancer, had significantly influenced their eating habits to improve nutritional intake. Many express a strong awareness of their dietary needs and the need for adaptation, the emotional and psychological aspects of dietary changes were discussed, with some participants expressing feelings of loss regarding previous food habits, such as a fondness for sweets and snacks. However, many also report positive outcomes from their dietary changes, such as feeling healthier. Health concerns were discussed by individuals and family-caregivers, some described the compromise between the quality and quantity of calories their relatives were eating. However specific health concerns regarding potential susceptibility to foodborne illness were discussed, as presented further in section 6.6.

Although some factors relating to mobility and the impact upon being able to go shopping were discussed in sections 6.1.2 and 6.1.3. During the discussion groups, the challenges faced by individuals over the age of 65, particularly those that were disabled, in managing daily activities like shopping, cooking, and mobility was explored. Many participants described the physical limitations that hinder their ability to perform these tasks independently. Ageing parents, often with mobility issues like hip problems, arthritis, and Parkinson’s, rely on family members for support, such as food shopping and meal preparation. These physical limitations also impact their social lives, reducing outings and making it difficult to maintain previous routines. Some participants noted that their relatives have difficulty accessing items in their homes, like food stored in under-counter fridges. Others use adaptive methods like prepared meal services to cope with physical challenges. Participants expressed frustration over the reliance on caregivers and the decline in independence, with some adjusting to the limitations by batch cooking or simplifying tasks. Despite the efforts of family members or carers, the physical and emotional toll on both individuals over the age of 65 and their family-caregivers are significant.

Several individuals discussed how their appetite had reduced as they had become older. However the decline in appetite was widely discussed by those that cared for their relatives, they discussed witnessing how their relatives’ appetites and interest in food had declined. Many family caregivers described their relatives as ‘picky eaters’ and how they were having to adapt to deal with this.

Some participants discussed the challenges they faced, or that their relatives faced in managing food and household tasks due to poor eyesight or vision loss. Several participants describe difficulties their ageing relatives encounter, such as being unable to read use-by dates and having trouble with small print on food packaging and cooking instructions. Some individuals are unable to cook due to visual impairments or health issues and rely heavily on ready meals or caregivers for assistance. One participant shared that they serve meals in a certain way to make it easier for their visually impaired relative to identify different foods. These points of discussion indicate the importance of accessibility in food storage, packaging, and preparation for those with declining eyesight.

The impact of diminished taste and smell on eating habits was widely discussed. Some participants mentioned losing their sense of taste which affected their relationship with food, while one participant noted that while their reduced taste makes it easier to eat repetitive meals, another expresses frustration in not being able to enjoy food, which also lead to concerns about not being able to taste if food has spoiled. Overall, the loss or alteration of taste and smell significantly affects these individuals' food choices.

A study of food insecurity amongst older people in the UK reported that within the older adult age group there are older people in very different circumstances for example 20% of people aged 75 years and older need support to leave their home (Purdam et al., 2019). This can have a dramatic impact on a person’s ability to buy and transport food home, which has been explored in a food safety context in this study.

Family caregivers were particularly aware of reduced appetites and how this results in the same quantities of food being purchased but not being eaten and therefore being subject to prolonged storage in the home, to ensure the safety of such food the use-by dates need to be adhered to, and refrigerators need to be operating at safe temperatures. Vision impairment also resulted in use-by dates being disregarded., or cooking instructions not being correctly implemented.

Social environment determinants discussed during the focus group discussion included how others influenced people’s relationship with foods. As indicated in Table 5, one of the widest discussed social determinants was the impact of living alone on the relationship with food shopping, cooking and eating. The social environment of individuals has a significant impact upon their psychological factors, combined these can significantly impact upon food shopping, storage, cooking and eating practices among adults over 65 in Scotland.

The presence of others significantly influences participants' cooking and eating habits. Many participants describe how they cook more or put in extra effort when cooking for someone else, such as a spouse, child, or grandchild. Some participants shared that cooking becomes a social activity, particularly when family members cook together, bringing enjoyment to the process. Social interactions and having family or friends visit to cook for seemed to inspire more effort and enjoyment in meal preparation.

The loss of a spouse or the absence of loved ones often resulted in a decline in cooking enjoyment and eating habits, with some relying on others to help with meals. For example, when living alone, participants expressed a decline in motivation to cook elaborate meals for themselves, often opting for quicker, simpler options like snacks, toast, or ready meals. For those who used to cook more frequently, especially for a spouse or family, cooking had become less appealing after losing a partner. Some participants reported feeling that cooking for one lacked purpose or that it had become a monotonous task and often resulted in preparing the same quantity of food as when cooking for two resulting in eating the same thing over a prolonged period of time. Often, living alone leads to reliance on batch cooking, frozen meals, or external help like food deliveries from family members. The overall theme is that food and cooking are not just about sustenance but are deeply tied to social interaction, companionship, and care. A sense of loneliness or a change in lifestyle, exacerbated by factors like mobility issues or the impact of COVID-19, has influenced their eating habits and overall attitudes toward cooking and food shopping. 

It has previously been suggested that the Health Belief Model overly emphasises cognitive constructs, neglecting emotional and social factors by overlooking cultural and social influences on health behaviours and assumes rational decision-making, ignoring emotional complexities (Alyafei & Easton-Carr, 2024). Therefore, by incorporating social determinants of health into the model it may give a deeper understanding of changing human behaviour (Resnicow et al., 1999), consequently by taking that approach in this project the findings highlight the impact of the social environment on shaping food-related behaviours among adults over 65 in Scotland. Indeed, factors such as living alone and social interactions impact motivation to prepare food, food handling practices, food storage habits, and overall dietary choices, which in turn may pose potential food safety risks.

One key concern is the reduced motivation to cook and eat fresh meals among those living alone. Participants often reported opting for ready meals, batch-cooked frozen meals, or repetitive food choices, which could increase the risk of improper food storage, inadequate reheating, and prolonged food consumption beyond safe storage durations.

Conversely, those who regularly cook for others exhibited higher motivation to engage in safe food handling and meal preparation, reinforcing the role of social support as a cue to action in the Health Belief Model (Rosenstock, 1974). Shared meal preparation and social interactions appeared to encourage safer food practices, this could be through peer reinforcement or having a sense of responsibility and accountability. However, even in social settings, misconceptions about food safety and habits can influence behaviours (Anderson et al., 2011).

Understanding how the social environment influences food safety behaviours is essential for developing targeted food safety messaging aimed at older adults. Further research is needed to explore how the social environment can be utilised to improve safe food handling and consumption practices among older adults.

Numerous points of discussion related to the psychological determinants, for example the groups with people over the age of 65 commonly discussed meal planning, lack of motivation and food enjoyment, other groups discussed cognitive decline among their loved ones. Examples of quotes are given in Table 6.

Some participants discussed having complicated relationships with food which often existed from childhood, with some describing self-destructive and self-sabotaging behaviours such as compulsive overeating or excessive snacking, while others simply viewed food as fuel.

A lack of inspiration and motivation to cook was often linked to living alone, as discussed in 6.3.2. Many participants express difficulty with meal planning. Participant 002, a vegetarian, finds it challenging to prepare diverse meals due to complex recipes and limited ingredients, leading to repetitive eating. Many participants shared their frustration with falling into routines and missing spontaneity in meal preparation, this was particularly the case for participant 112, who in section 6.2.2 had previously described how mobility problems prevented them from gong to the supermarket. Several participants mention a decline in their enjoyment of food and cooking over time. Convenience was a key factor for several participants, with some opting for ready-made meals or simple, repetitive dishes due to exhaustion or lack of interest in cooking, or simply not being bothered to cook.

Although Alzheimer’s disease is a physical illness, that damages the brain it could be classified as a biological condition, however because it causes progressive memory loss and cognitive decline, for the purpose of this analysis it has been grouped as a psychological factor. Nevertheless, for future iterations of the model, it is suggested that all psychological factors and biological factors are grouped as health factors.

In the general discussion groups, some expressed concerns about memory loss affecting their ability to manage food. Some forget to buy essential items, while others may forget about leftovers or fail to plan meals adequately. However, in the discussion groups with individuals who supported relatives over the age of 65 with related tasks, cognitive decline was a key theme. The discussions focused on how ageing and memory issues, especially related to dementia and Alzheimer’s, had a significant impact on food management and eating habits. 

Cognitive decline was a recurring issue, with participants mentioning that loved ones with dementia struggle to remember what they’ve eaten or how to prepare food. This has led to instances of unsafe food storage, like leaving food out for days or misusing kitchen appliances, necessitating external help from carers or family members.

There was widespread concern among family caregivers about how dementia and Alzheimer’s was affecting the food related behaviours of their loved ones. Significant discussions were also held regarding the impact of caregiving and being the sole food provider of family caregivers. This was often balanced with full time work and younger families.

Psychological factors significantly impact food safety behaviours among older adults. Low motivation, difficulty with meal planning, and cognitive decline can lead to unsafe food storage, improper reheating, and increased reliance on ready meals. Cognitive decline, including dementia and Alzheimer’s, further exacerbates food safety risks, with reports of forgotten meals, improper food storage, and unsafe appliance use. Family caregivers face challenges ensuring food safety while balancing other responsibilities. Addressing these issues requires clear food safety reminders, meal planning support, and caregiver assistance programs to promote safe food practices for older adults.

Many of the participants discussed the impact of finance on their food shopping and cooking habits. Discussions related to the increasing cost of food and the increasing cost of fuel and energy required to heat homes and cook food. Food insecurity because of the cost-of-living crisis was a concern to many participants in most of the groups. Many recalled how costs increased during the Covid-19 pandemic, but had remained high, others were concerned about the cost of heating and the cost of petrol, all of which impact on available finance for food:

“I think the supermarkets used the pandemic to throw their prices up unnecessarily and they’re not bringing them down and that’s wrong. But there’s nothing we can do about it; we need food to eat. So, they’ve made a lot of stuff extortionate prices, but you still need to eat so you’ve got to buy it.” (Participant 118).

“Last winter, when the energy costs were just going up… It did impact on everything else because my fuel bill, I have a husband at home who’s not a well man so, so heat for him is an essential. It’s not something you can do without. But it impacted on everything that I did because mine went from, £100 to £350 a month. That’s a massive increase which impacted on every other area of my life, including food. So, before that, if my husband said, “oh, I think I fancy a steak tonight”, that was easy, I’d go get one, but not now... Although t’s coming down in July, then it’s going to start going back upwards from October. Now, I’m very conscious of that fact, but it definitely impacts on what you’ve got to spend on other things, especially on food.” (Participant 121).

“I realised that when petrol prices just went sky high, I was really conscious about how often I used my car. So, I am much more conscious of how much I pay for food than I ever have done largely because even though I’m still working my income has reduced and so I cut my cloth accordingly. It’s not that we starve at all, it’s just that I’m careful about what I buy.” (Participant 130). 

As a result of this, many cost-effective decisions were made both when out shopping for food (Table 7), and when cooking food at home (Table 8). For example, some suggested prolonged storage of foods with short shelf life, whereas other chose to freeze such foods, in relation to this, there is a need to ensure cooking temperatures and appropriate thawing methods are followed. 

There was a great deal of discussion regarding changing the type of supermarket where they purchase groceries from, for example opting to shop at discount supermarkets such as Lidi and Aldi, instead of the 'big four' supermarkets – Tesco, Sainsbury's, Asda and Morrisons. Some described visiting multiple supermarkets to benefit from offers and discounts and described buying some items in bulk to benefit from such offers. While some described meal planning before going shopping, others described meal planning while shopping as a result of what was on offer in the supermarket.

When preparing food at home, many described using smaller cooking appliances such as air friers, pressure cookers and microwaves instead of using larger appliances such as the oven. Nevertheless, some discussed that if they were using the oven, they would use it to batch cook multiple items and utilising the freezer for storage.

It is evident that at times, people have to make challenging decisions that are based on economic determinants, for example, deciding between eating something that is potentially unsafe (e.g. beyond the use by dates) or wasting that food and going hungry. For future campaigns, it is important to be personable and acknowledge the situation that individuals may be in and present options to mitigate food safety risks or food wastage at an earlier point, e.g. utilising the freezer. 

Although some batch cook for convenience, others do this to spread the cost of food purchase and reduce energy costs.

However, people need to have the space to store what has been batch cooked: 

“I can’t batch cook because I just don’t have the room for it, it’s going to go into the fridge and sit there for three days and then I’ve kind of got a dilemma that I have to use it and always eating the same thing (Laughs).” (Participant 084)

“Well food will last in the fridge for up to five days if you cook it as batch cooked, as long as you don’t mind eating the same thing.” (Participant 090)

Although some described themselves as “yellow sticker aficionados” as a money saving approach, others felt that they no longer provided value for money, particularly if the food has to be consumed promptly:

“I do feel though, yellow stickers don't really have much value anymore because it seems to only be a few pennies, whereas before it was seen silly money you were getting off things because they were close to their use by date. But now you know, it's very close to the original price. And the value in that is reduced if it's only got, you know, 12 hours where you can use it.” (Participant 049).

Some participants were aware of food safety; however, finance had the biggest impact on food choice:

“My husband is also diabetic, and he’s also prone to infections and then my daughter with her autoimmune disease she does, so we’ve noticed a real difference, which is why we tend to be careful, but finances dictate what we can afford to buy in terms of food, so we buy the cheap stuff but try and keep an eye on it.” (Participant 110)

Although many were concerned about the cost of food and the cost of energy to cook or heat their homes, some such as participants 041 and 027, indicated that economic factors did not impact on their food shopping decisions.

“I think I'm in a fortunate position, the cost-of-living crisis doesn't really affect us, it certainly doesn't affect me, but it is money, and I'm aware of a lot of people who have a very tight budget and that's not me. I'm lucky and it has a huge effect on what they're able to buy.” (Participant 041).

“I still work part time, and my husband has his own business, so we're not getting any issues with finance. So, I generally just buy, you know, if I want something, I will get it.” (Participant 027).

Food safety considerations are increasingly impacted by economic factors such as financial constraints, as participants adapt their shopping, storage, and cooking habits due to rising costs. Many prioritised affordability by shopping at discount supermarkets, buying in bulk, and seeking discounted short-dated foods, which raises concerns about safe storage durations and food safety. Freezing food is a common strategy, but ensuring safe thawing and cooking methods is essential.

With the shift towards using smaller and more energy-efficient cooking appliances, such as air fryers, microwaves, and pressure cookers, unfamiliarity with these devices could pose food safety risks. Individuals who have cooked using traditional methods, may have difficulties in adapting to new cooking methods that increase the risk of foodborne illness, for example, using an air fryer or pressure cooker without knowing the appropriate settings for different types of food may result in uneven cooking, particularly if cooking times and temperatures are not well understood, and especially in the absence of cooking instructions specifically for air fryers. Therefore, it is important to provide clear guidance on how to safely use these appliances but also ensuring that future food safety messaging refers to reaching safe internal temperatures to prevent the risk of foodborne illness. 

The preference for batch cooking to save on both time and energy may result in foods being subject to prolonged storage, repeated reheating or unsafe thawing practices.

Financial pressures sometimes lead to difficult choices, such as consuming food beyond its use-by date or relying on food banks with limited cooking resources. Future food safety campaigns should acknowledge these economic realities and provide practical guidance on minimising food waste while ensuring food safety.

Impact of economic determinants upon food shopping, purchase decisions, food storage and eating practices among adults over 65 in Scotland

Impact of economic determinants upon food shopping, storage, cooking and eating practices among adults over 65 in Scotland

There is conflict in research regarding the two constructs that contribute to perceived threat (Jones et al., 2015), some suggest that perceived susceptibility is a better predictor of perceived threat than perceived severity (Janz & Becker, 1984), as perceived severity often has insufficient variance (Carpenter, 2010). Others suggest that combining perceived susceptibility and perceived severity as a single construct is beneficial (Champion & Skinner, 2003). These points of view were considered by the researcher, although many studies do not utilise the Health Belief Model in its entirety (Jones et al., 2014), it was decided that the data would be coded according to the two constructs that make up threat perception and discussed accordingly. 

From the discussion groups, it is evident that perceived susceptibility to foodborne illness and the perceived severity of foodborne illness varied between individuals over the age of 65 and those who support relatives over the age of 65. As can be seen in the sentiments below, family caregivers perceive that their relatives are not only more susceptible to foodborne illness but that the consequences of such illnesses could be significantly more severe due to age-related frailty or pre-existing health conditions. The perceived threat of foodborne illness among family caregivers had a positive impact on food safety practices being reported.

In the Health Belief Model, the perceived susceptibility is defined as an individual’s belief about the likelihood of getting an illness, disease or condition (Glanz et al., 2015). For example, in a food safety context, a person must believe that they are at risk of foodborne illness before they are willing to act by implementing recommended food safety practices.

Very few people over the age of 65 believed themselves to be susceptible to foodborne illness. Many stated they did not think they were at risk and indicated a perception of invulnerability (Table 9). It was perceived that foodborne illnesses were most likely of being acquired because of food consumed away from the home. 

Many were not aware of immune system changes associated with age, however when provided with such information they were able to understand why susceptibility to foodborne illness increased with age.

For example, Participant 121 perceived her husband to be susceptible to foodborne illness because of cancer treatment and did not perceive herself as susceptible despite having diabetes, using proton pump inhibitors and being over the age of 65.

“My husband would be at risk of food poisoning, because he has cancer. But he’s never been ill with anything like that. It wouldn’t apply to me, but the possibility would be there for him...”

However, when provided with information about immune system changes resulting from medication, underlying conditions and age-related changes, participant 121 was able to comprehend her susceptibility to foodborne illness and believed that knowledge was power to facilitate behaviour change: 

“...The thing is with this, I came in here, I’ve never even considered my immune system. I fit four of those categories, I’m not pregnant, it’s the only one I’m excused from [laughter].  Now whilst I know that he is more vulnerable, I’ve always assumed he’s vulnerable because he’s got cancer and he’s having ongoing treatment.  I’ve never ever applied that to me, and I’ve got three things there that applies that to me.  So perhaps I ought, you know, I see it slightly differently to you, I think information is power.  If you don’t know something, you can never choose to take steps whereas if you do know something.” 

Conversely, some individuals were already aware of their susceptibility of having a foodborne illness as a result of previous illness, this resulted in the implementation of some food safety practices as described by participant 001 (Table 8). Similarly, there were some individuals who were aware of their susceptibility to foodborne illness due to underlying autoimmune diseases such as type-1 diabetes and rheumatoid arthritis or medications.

When prevalence of foodborne illness was shared with participants, some were shocked:

“I was quite shocked to hear that. That it's that older generation because I'm made the assumption wrongly, maybe that it would be younger people. But I was quite shocked to hear that it is the older generation that are such a high level of it.” (Participant 035).

Perceptions were different among family caregivers, although participant 049 believed their father was “completely unaware of his vulnerability to food poisoning”, likewise participant 006 deliberated regarding her parents that... 

“I don't think mine have a clue that they are at an increased risk of becoming ill, no. I think they're aware that if they have a bug or something that it's much harder to shake it off. I don't think they're aware of potential food poisoning or their immune system being less robust.” (Participant 006).

Whereas others suggested their relatives maybe aware of the susceptibility, for example, participant 005 described that their mother was particularly susceptible to foodborne illness, and believed their mother was aware of her susceptibility and this resulted in a behaviour change to ensure the safety of food:

“I would say my mum she is more susceptible of becoming ill. In terms of her physicality. I think that might be one of the reasons that she's more prone to buy things that can be frozen and aren't fresh, for longer storage. My mum's quite different now, in that she reads every date. She'll throw something away that's showing that date, even if it doesn't look bad to me. She's very worried about things upsetting her tummy now, more so than she ever was. She wouldn't use to bother with use by dates or whatever… So, she's very cautious now, she's more aware that she's at risk and more cautious and I think that's why she's much more cautious about things that are out of date and how she stores food. Her fridge is actually quite bare compared to what she used to have in it, everything's in the freezer now. And I think that in her mind is one way of controlling all of that, keeping it very fresh and not letting things go off and upsetting her tummy.” (Participant 005).

Similarly, participant 047 suggested that their mother may have an awareness of her vulnerability to illness due to visible physical changes:

“So, I was going to say my mum is aware of her vulnerability now, maybe two or three years ago, perhaps less so, but certainly now she's got a physical marker because she started falling, so that's raised her awareness. She's also seen just how much weight she's lost since October, which is a stone and 1/2 to take her down to 7 stone. And I suppose because I have continually harped on about food hygiene, she has kind of adopted that mindset. She's got no sense of taste or smell, but she'll hand me the milk jug, you know, and she’ll say “What do you think? Do you think that's ok?”, so I say “Well, for reassurance, mum, let's tip it.” So yeah, I think she is now aware of her vulnerability.” (Participant 047).

Several participants who provided food for relatives over 65 were aware of their increased risk of foodborne illness. As a result, they avoided certain food choices or practices they might use for themselves and their families. This caution was due to their awareness of their older relatives' immunosuppression and frailty (Table 9). Some were aware of frailty as they could visibly see this decline in their relatives, others had become aware as a result of their carers such as participant 049 who was a chef and Participants 047 and 046 who were both healthcare professionals, and Participant 131 volunteered to cook at community lunches at a church.

Perceived severity refers to a belief about how serious an illness or condition is, including the consequences of contracting it or leaving it untreated (Glanz et al., 2015). When applied to a food safety context, this relates to an individual’s belief of the physical consequence of contracting a foodborne illness such as duration of illness or outcomes such as death, disability, pain or social consequence such as the ability to work.

As indicated in Table 10, family caregivers often exhibited a strong awareness of the potential severity of foodborne illness, particularly when it comes to the vulnerability of their elderly relatives. Similar to the points raised regarding perceived susceptibility to illness, caregivers recognise that foodborne illness could have serious or even life-threatening consequences for their loved ones. For example, Participant 048 expressed concern about the potential impact of foodborne illness on her mother-in-law, stating that “she’s of a certain age, getting food poisoning, I wouldn't like to think what the consequences [would be] because as I say, there's not enough reserves to fight that.” This statement reflects an acute awareness of the diminished physical resilience that often accompanies ageing, implying that even a relatively common illness like food poisoning could result in dire consequences for someone with limited physical reserves.

Participant 046 was particularly aware of the potential severity of foodborne illness to her ageing mother due to her specific health conditions stating, “food poisoning is not something she would survive, you know, she just she's got kidney failure”. Similarly, Participant 047 emphasised that her mother “is not in a fit state to withstand that type of insult,” indicating the frailty and compromised health of her elderly parent. The use of the word "insult" in this context highlights the belief that any illness, particularly one like foodborne illness, would be a significant and harmful burden on her mother's already fragile condition. Participant 047 went on to describe that because of having worked in an intensive care unit, she was aware of how severe foodborne illness could be among older people, she compared how symptoms may be mild for younger individuals or those without a compromised immune system and that people were generally unaware of the potential severity.

Although those with underlying conditions discussed their susceptibility to foodborne illness, with the exception of Participant 031, the perceived severity of foodborne illness was not discussed among individuals over the age of 65. The findings from the discussion groups indicate the significant concerns family caregivers have regarding the potential impact of foodborne illnesses on their vulnerable ageing relatives.

Perceived susceptibility to foodborne illness among family-caregivers and adults over 65 in Scotland

Perceived severity of foodborne illness among family-caregivers and adults over 65 in Scotland

Perceived benefits are the beliefs about positive features or advantages of recommended action to reduce threat. For example, the recommended practice may reduce the threat, however there may be other tangible benefits. Perceived barriers are defined as possible obstacles to implementing the recommended action, or can refer to the perceived negative consequence of the action (Glanz et al., 2015). 

A meta-analysis of the effectiveness of the variables of the health belief model in predicting behaviour, benefits and barriers were consistently the strongest predictors of behaviour (Carpenter, 2010), furthermore, perceived benefits and perceived barriers may be able to better predict behaviour when the perception of threat is greater (Jones et al., 2015).

In a food safety context, the evaluation of behaviour incorporates the perceived benefits of the food safety practice and the perceived barriers to the food safety practice, it also incorporates the perceived self-efficacy to perform the behaviour. 

As with other constructs, differences were established in the evaluation of behaviour to counteract the threat among individuals over the age of 65 and family-caregivers. Often people evaluated the perceived benefits and discussed them in contrast to the negative consequence or barriers. For example, in the context of following storage duration and date labels, often the behaviour to counteract the threat of foodborne illness was to dispose of the unused opened food or food beyond the use by date, the negative consequence of this was food waste and the perceived waste of money resulting from this, however the perceived benefit was the avoidance of foodborne illness.

The perceived benefits of food safety recommendations, related to specific practices, rather than food safety as a broader concept. Several participants perceived the benefit of following food safety guidance to be the prevention of foodborne illness, this was often indicated to be the motivation, for example, some reflected on previous experiences of foodborne illness and not wanting to experience such illness again (see motivation section 6.7.4 and Table 14). Despite having not experienced foodborne illness, Participant 020 described not taking risks with food to avoid food poisoning. 

Some of the perceived benefits of food safety practices that were discussed were often aligned with the motivations of individuals to adhere to such practices. Motivations are discussed in section 6.7.4. As indicated in Table 11, Participant 103 shared some of her food safety practices along with the perceived benefits and barriers, she believed that not consuming food beyond the use by date was potentially preventing illness, but discussed the opposition she faced from friends and family as they perceived the practice to be wasteful.

After stating they follow the use by dates on foods, Participant 031 was asked what they believed the benefits were from following the use by dates, they stated that it gave them “more confidence in using the product.” Similarly, Participant 035 believed that a temperature probe would be beneficial to avoid foodborne illness and give confidence that the food was safe to eat. 

Family caregivers' perceived benefits were closely linked to their understanding of their loved ones' susceptibility to illness and the severity of its impact.

It was of interest that because of the discussion groups, some participants, such as Participant 006, could now perceive benefits in certain food safety practices such as using a refrigerator thermometer and considered purchasing one.

Potential barriers to food safety practices in the discussion groups related to various factors, including lack of knowledge, complacency, historical attitudes, financial constraints, and emotional resistance.

Although there was much discussion about the benefits of food safety tools such as temperature probes and refrigerator thermometers, some participants expressed uncertainty about such food safety tools. For instance, Participant 004 discussed that they would consider using a temperature probe if provided with one but went on to indicate they lacked the knowledge of what temperatures to aim for in cooking. Indeed, others also suggested they would use one if they were provided with one, suggesting that in addition to a lack of awareness regarding recommended cooking temperatures, access to such tools may be a potential barrier. Likewise, Participant 001 indicated an interest but stated that they had never have thought about using a temperature probe, and Participant 005 also indicated she would consider buying a temperature probe if she had clarity around risks (Participant 005).

For some, there was a misunderstanding regarding food safety practices, for example the researcher asked how many people washed raw meat and poultry, as indicated in the passage below. Participant 002 admitted to having previously washed raw chicken in an attempt to make it cleaner, this points to a potential lack of understanding of proper food handling as a barrier, the conversation indicates the specific cues to action that resulted in the appropriate food safety practice being adhered to:

“I used to always be washing a bit of chicken” (Participant 002)

“What was your reason for doing that?” (researcher).

“Trying to make it cleaner” (Participant 002).

“Did you think you were achieving that?” (researcher).

“No, I definitely wasn't. You know, I was just spreading the germs all around the sink. Just a lack of knowledge really. I know I've I stopped doing that because my wife told me I was just spreading the germs all over the sink” (Participant 002).

“Was that information credible enough to make you stop doing it?” (researcher).

“Absolutely. Yeah. I mean, I've learned later on, I’ve read articles in newspapers and so on that that was quite a dangerous thing to do, you know” (Participant 002).

As indicated in Table 12, Participant 001 also discussed previously washing raw chicken in an attempt to remove salmonella from raw chicken.

Discussions highlighted that longstanding attitudes and mindsets can be barriers to following food safety recommendations, such as adhering to use-by dates. Participant 110 reflected on childhood experiences and how they influenced their views on food safety. They also mentioned that financial constraints can make it difficult to avoid consuming food past its use-by date.

For future food safety education campaigns, it is important to recognize that financial limitations may prevent people from discarding expired food. Some may see disposal as financially unfeasible or wasteful. To address this, consumers should be made aware of strategies to avoid this dilemma, such as using freezers to extend food shelf life.

Significant barriers to ensuring food safety practices were discussed among the family caregivers, for example, many of the family caregivers didn’t live with those they cared for and were unable to check as frequently as they might like to. They also found it challenging disposing of expired food, when it wasn’t their food, particularly when parents were aware of the food being disposed of and the family caregiver felt that they didn’t have the authority to dispose of the food as discussed by Participant 045.
 

Perceived benefits of food safety practices among family caregivers and adults over 65 in Scotland

Perceived barriers to food safety practices among family caregivers and adults over 65 in Scotland

Many participants did not believe that foodborne illness was likely to occur as a result of food consumed in their own home, that the domestic environment was the least likely location, and they had confidence in their ability to prevent foodborne illness:

“I feel it is quite unlikely to happen at home… but it’s much more likely to be from food that isn't vegetarian or eaten out.” (Participant 020).

Although perceived self-efficacy relates to a person's belief and confidence in their ability to perform the behaviour, in the context of food safety, it may be suggested that overconfidence from cooking experience may prevent recommended food safety practices being adhered to, again this was often in relation to using food safety tools such as temperature probes. For example, some participants expressed confidence in their cooking abilities and relied on their experience rather than tools (Table 13). Participants 028, 081 and 110 mentioned that they do not use a thermometer, believing they can assess if food was cooked based on their experience, they were confident that they had the ability to ensure food safety without food safety tools. This complacency and overconfidence can lead to overlooking proper safety measures and may be a barrier to people accepting food safety educational messages in future, therefore it is important to address and acknowledge the confidence that people have in their abilities, but that it may not be sufficient to ensure food safety. Similarly participant 001, believed that her food was less likely of being undercooked than others and indicated confidence in relation to this as she was “only cooking small amounts”.

Self-efficacy in their own judgment of determining food safety often meant use by dates were disregarded when people believed they could tell that food was safe to eat via appearance, taste or smell, this confidence was often based on their experience of cooking and using “common sense” as discussed by Participants 004, 082, 091. Further to this, participants 054 and 055 discussed becoming more relaxed about food safety practices with age and experience.

It is easier for health educators to design behaviour change programs if the recipient’s motives and attitudes to changes in health habits are known. It has been suggested that understanding the motivations for food safety behaviours has the potential to improve the quality and effectiveness of educational programs in the future (Schafer et al., 1993). 

Motivation for change depends on the presence of a sufficient degree of perceived risk in combination with sufficient self-efficacy. Perceived risk without self-efficacy tends to result in defensive cognitive coping, such as denial, rationalization, and projection, rather than behaviour change (Snetselaar, 2001).

During the group discussions, a number of different motivations to implement food safety practices were discussed, these ranged from personal experience to the practical benefits and were broadly related to previous experience with foodborne illness or having underlying health conditions and taking medications that impact upon immune function. Whereas for some they were motivated by an interest in food safety gadgets such as temperature probes and thermometers. 

As indicated in Table 14, previous experience of a foodborne illness motivated individuals such as Participants 024, 032 and 035 to be more cautious in relation to food safety practices in the home, whereas Participant 067 discussed not being bothered about food safety practices because they hadn’t experienced foodborne illness and consequently weren’t motivated to follow some recommended food safety practices.

Participant 066 discussed that their motivation to use a refrigerator thermometer and ultimately purchase a new fridge was to ensure the safe storage of medication, nevertheless a benefit of this was ensuring that food was safely stored. Some, such as Participant 080 was aware of the importance of fridge temperatures, she had not been motivated to purchase one until she saw a refrigerator thermometer for sale and believed it would be useful for her.

The purchase of an air fryer motivated participant 024 to purchase a temperature probe. Whereas it was of interest that Participant 057 described that when she was cooking meat for herself and her family, she sometimes wasn’t sure if chicken was always cooked, but she wasn’t overly concerned, however when her children were learning to cook, she advised them to use a probe, and also adopted the practice herself: 

“When the children got a wee bit older and they were cooking for themselves, it was “how do we cook chicken?”, “How do we do it?” And I said, “Well, if you really want to be sure it’s cooked, get a probe.” And I got one as well.” (Participant 057).

As previously stated, the perceived benefits and motivations are often linked. As discussed in the section describing perceived benefits of food safety practices, Participant 20 described being motivated to not taking risks with food to avoid food poisoning.

In their role as family caregivers, some participants felt motivated to take responsibility for ensuring the safety of their loved ones' food, as they believed their relatives were no longer capable of doing so themselves.

Some participants, such as Participant 105, lacked motivation for food safety practices, viewing them as unnecessary or burdensome. For example, skipping the use of separate chopping boards despite understanding the potential benefits.

Despite the lack of clarity in findings between perceived benefits and perceived motivations, these findings provide valuable information into personal motivations for improving food safety behaviours in the home, these can indeed be utilised by Food Standards Scotland to help inform the development of future food safety campaigns, such as: utilising personal stories of foodborne illness experiences to highlight the severity of illness. The findings also show the motivation of those individuals who are aware of their personal susceptibility to foodborne illness and infections due to underlying health conditions or medications, this indicated the need to facilitate widespread communication of who the clinically vulnerable groups are, this is particularly important as many who had certain underlying conditions were not aware of their increased susceptibility to illness. 

Given the interest and willingness to engage with gadgets, there are opportunities to encourage the use of refrigerator thermometers and temperature probes that simplify safe cooking and storage practices in the home, these need to be more visible for consumers and need to be normalised as part of everyday cooking.

It may be suggested that focusing on relatable experiences, emphasising the practical benefits, and increasing accessibility of key food safety tools could effectively motivate individuals over the age of 65 years to prioritise food safety practices in the domestic kitchen as part of daily life.

Cues to action are the stimulus needed to trigger the decision-making process to accept a recommended health action (Glanz et al., 2015). Cues to action include a range of triggers to the individual taking action and are commonly divided into factors which are internal or external to the individual (Meillier et al., 1997), the later can include mass media campaigns or advice from others (Janz & Becker, 1984). However, responses to cues-to-action vary among individuals, it may be suggested that the lifestyle factors and the perceptions of individuals may impede or help facilitate food safety practices (Meillier et al., 1997). It has been previously suggested that perceived susceptibility and perceived benefits are only relevant when activated by other factors termed as cues to investigate action (Glanz et al., 2015).

In the food safety context, cues to action refer to triggers for accepting recommended food safety practices. Previous research identified three key cues to action in relation to food safety behaviours, these included; media such as mass media or printed media; communication such as interactions between parents, peers or teachers; and food labelling found on food packaging (Shafiee et al., 2014). Communication researchers hypothesise external cues such as campaign exposure as the predictor variable (Jones et al., 2015).

One of the most widely discussed cues to action in this study were Food Standards Scotland media campaigns to discourage the practice of washing raw meat and poultry to prevent cross contamination of the domestic kitchen environment, as previously mentioned, in relation to perceived barriers to positive food safety practices, some people believed they were doing the “right thing” in washing raw poultry to “make it cleaner” or “remove the germs”. As indicated in Table 15, information regarding the cue to action are shared, how credible information meant it was easy for some people to stop the practice. Some could recall the importance of the messaging, whereas the visuals used remained with others.

For the development of future effective food safety campaigns, there are opportunities to learn from previous campaigns that acted as cues to specific action. However, in the context of stopping the behaviour of washing raw poultry it is very different to adopting a new food safety behaviour. Although some were glad to stop the practice of washing raw meat as they disliked handling raw meat and saw it beneficial in having one less food preparation task, others described the change in behaviour being challenging as they were so familiar and accustomed to implementing the practice.

Previous research with older adults with chronic illness suggests that cues to action which provide information, having underlying knowledge and consulting with others can trigger adoption of self-care (Chou & Wister, 2010). 

In addition to ensuring food safety messaging include cues to action it is essential that future food safety campaigns are delivered in appropriate and effective ways to the target audience. Therefore, during the groups discussions preferences for future food safety education and communication were explored.

Many referred to trusted sources of information such as medical professionals, Food Standards Scotland, and the NHS website to provide clear, factual information. It was suggested that all communication from FSS needs to be evidence based, if statistics are broad or specific it doesn’t matter but they need to be backed in evidence. Although some the need to avoid overly alarming language or statistics that could cause unnecessary fear. Others believed this to be necessary to ensure the impact of the messaging.

Participants discussed the importance of delivering short, sharp messages through traditional media such as campaigns on TV, radio and other media including the printed press and social media to raise awareness. In addition to advert type messaging, many discussed they would also like to receive written information in the form of booklets or leaflets, many discussed that receiving a paper-based information resource was preferable as it would be revisited. Some mentioned using social media would make it feel “right in your face” and more and more older people are using these social media platforms. Many believed that there would be value in using a variety of different approaches to get the message across.

It was suggested that there was a need to focus on educating younger generations about food safety practices, rather than just targeting older adults. Some participants suggested that food safety education needs to come at an earlier age, not just delivered when individuals are at a stage of increased susceptibility, many suggested that food safety should be incorporated into the school cuticular, particularly as many children wouldn’t receive such information at home.

Once again, concerns regarding the lack of food safety awareness among carers and care providing companies:

“I just feel that some of the carers and some of the companies don’t train their staff well enough in food safety and food hygiene, nor do they have time when they go and visit people” Participant 066

It was discussed that there is a need to tailor the information to address specific conditions or vulnerabilities that increase susceptibility to foodborne illness, why individuals are at risk and what they can do to reduce the risk of foodborne illness.

There was a great deal of discussion regarding targeting individuals aged ≥65 years with some suggesting a preference for ‘older people’ rather than ‘elderly’.

“If you want older people to read it, you need to say older people. Because if you say elderly. That’s my grandma, you know. If it says elderly on it, I just won’t pay any attention to it”. 

“I would take notice of older, but definitely not elderly and what really annoyed me is when you say over 65 and the government wants people to work until 67 and 70” (Maureen)

The consensus was that resources should refer to people over the age of 65, explain why they are susceptible, how this increases with age, to ensure clarity without using a term that may be derogatory for some. Some suggested the need for resources that susceptibility isn’t something that ‘suddenly happens on your 65th birthday’, but a gradual progression with age.

During the in-person discussion groups, participants were presented with the three different risk statements regarding clinically vulnerable groups to listeriosis. These ranged from the shortest and the least complex statement which was a variation on the standard YOPI categories (Figure 2), an extended YOPI classification which defined specific chronic illnesses and treatments/medication identified in this report that result in reduced immune function (Figure 3) and a statement providing extended YOPI categories specifically defining why the listed groups are clinically vulnerable to foodborne illness which contained the most information (Figure 4). The statements were colour coded and presented to the participants in the ascending order of complexity. 

The first statement reviewed during the six in-person discussion groups was the variation on the standard YOPI categories (Figure 2). 

Figure 2. Risk statement (a variation on the standard YOPI categories) presented to the focus groups

Although some participants liked the simplicity of the figure 2 statement (Figure 2), the general consensus among the groups was that the statement was “too generic” and did not provide sufficient information. Several participants suggested that the generality of it would result in it being disregarded. This can be illustrated by the comment made by a participant in group 3: 

“I feel I would disregard it… I think it’s because it’s so general. There’s so many things that they warn you about, it’s if you’re pregnant, if you’re over 65, and really, I would just look at that and think, “Oh yeah, just another one”.” (Group 3, Respondent) 

The second statement reviewed during the discussion groups was the extended YOPI classification which defined specific chronic illnesses and treatments, or medication identified in this report that result in reduced immune function (Figure 3). 

Figure 3. Risk statement (extended YOPI categories defining chronic illnesses and treatments that result in reduced immune function) presented to the focus groups

In comparison to the statement in figure 2, the figure 3 statement was more widely discussed. Many preferred the inclusion of specific conditions and medications that result in reduced immune function. Some suggested that this would catch their attention as is refers to specific conditions. 

“I would take far more attention of this because it mentions several things that are important to me. I’m on immunosuppressants. So, there are things there that trigger me so I would immediately read that with more interest and take more consideration of it.” (Group 3, Respondent 5).

“And the list of all of the people who can be affected, detailed list, because I don’t think I would have associated diabetes when I read the first one and I have a friend with diabetes, and I definitely didn’t know that.” (Group 4, Respondent 5).

However, several individuals suggested that they may not take notice and did not perceive themselves to be vulnerable, even though they had underlying conditions listed in the risk statement. This was often accompanied by the false sense of acquired immunity, or perceptions of invulnerability and optimistic bias. As previously discussed, such perceptions may undermine food safety messaging (Evans & Redmond, 2019c) and future messaging needs to combat such perceptions. 

“Well, I’ve got diabetes Type 2, but it doesn’t worry me… Well, if you’ve eaten in some of the places in the world, I’ve eaten you become immune to these sorts of things.” (Group 1, Respondent 5). 

“I’m over 65. And I think you think, “Well I’m careful so it won’t happen to me. I wash my hands; I look after my food.” And that may be why, I don’t know, people over 65 maybe are more susceptible, like living on their own, having foods that have maybe got out of date because they can’t afford to, you know, buy things frequently or just because they don’t eat it fast enough. I don’t know if that’s what makes people over 65 more vulnerable.” (Group 3, Respondent 4). 

“Well, I tick a lot of those boxes. I didn’t realise that. Does it make me think that I am more susceptible? Well, I’m going to say no to that” (Group 5, Respondent 3). 

“…if somebody who’s diabetic, that’s a healthy diabetic, would read it and think, that’s rubbish I’m diabetic, I’m fine, so it’s not that easy. I know it’s not that easy, but I think that has to be addressed somewhere” (Group 6, Respondent 3).

Although some participants acknowledged the need for more information regarding vulnerable groups, they were concerned that the level of information in the figure 3 statement would prevent people from engaging with it: 

“The figure 3 statement tells it like it is. I find that figure 2 is basically sugar-coating things, isn’t it, and people need to know this. I think between the two statements, one is shorter and easier to read, who is going to take the time to read the whole of figure 3. So, it’s, there’s more information in figure 3 but many people get that, they won’t get past the first paragraph, and they will just go hmm and wander off.” (Group 5, Respondent 5). 

It was concluded that although the figure 3 statement provided more information about who’s vulnerable, it did not make individuals over the age of 65 years, with listed underlying conditions believe that they were susceptible to foodborne illness. 

“It’s obviously got a lot more information there. I still don’t feel vulnerable.” (Group 6, Respondent 1).     

“Doesn’t make me feel more vulnerable either.” (Group 6, Respondent 2). 

The final risk statement that was discussed during the six discussion groups provided the extended YOPI categories which specifically defined why the listed groups are clinically vulnerable to foodborne illness (Figure 4).

Figure 4. Risk statement (Extended YOPI categories defining why the listed groups are clinically vulnerable) presented to the focus groups

Although some believed the description to be too long, others felt it to be important and informative. It was discussed that the visual presentation of the information (bold and bullet pointing) made the statement accessible and allowed for a quicker summary by the individuals who felt that the statement was too long: 

“Sorry, I fell asleep. It’s far too long.” (Group 2, Respondent 3). 

“I find it very interesting actually, very informative. What you’re saying is all these conditions have impaired white blood cell production, which I just find interesting finding out things like that.” (Group 3, Respondent 4). 

“I think it very much depends on the communication. I like the figure 3 one because it’s quick and easy but it’s still comprehensive, and there is lots of things in it that I can go and look up. The figure 4 one is obviously much better but it’s longer and people do tend to have very short attention spans these days. So, you might not read it and then not go and investigate.” (Group 3, Respondent 5). 

“It’s comprehensive, isn’t it but you can pick it, it’s got the highlighted bits.” (Group 5, Respondent 3). 

“So, you can look at the bullet points and say well, that doesn’t affect me, that would affect me… and then you don’t waste time reading all the bits that you don’t need, you know, and you just go straight to the one that you do.” (Group 5, Respondent 6). 

“I like it because it explains why these people are vulnerable.” (Group 2, Respondent unknown). 

Many of the participants expressed that they have related to the statement and were surprised to learn that they were at an increased risk of foodborne illness: 

“So that’s new to me, a person over 65... I didn’t know that.” (Group 2, Respondent 4). 

“I didn’t know that. I knew that pregnant had to avoid soft cheese and all that sort of stuff because of listeria but I didn’t realise that people over 65 were more susceptible.” (Group 4, Respondent 5). 

“I fit three of those, and my husband and I between us fit four of those. I’m not pregnant. It’s the only one I’m excused from [laughter], but we fit four of those. Now whilst I know that he is more vulnerable, I’ve always assumed he’s vulnerable because he’s got cancer and he’s having ongoing treatment. I’ve never ever applied that to me, and I’ve got three things there that applies that to me. So perhaps I ought… I think information is power. If you don’t know something, you can never choose to take steps whereas if you do know something, you could either – react by ignoring it or you can act… you have a choice. Yes, you have a choice about how you deal with the situation, and I think, always think, knowledge is power. It does have a scary side, no question but that’s just what it is.” (Group 5, Respondent 3).

“I have never thought I was vulnerable, but I think as you get older, you don’t really want to think you’re getting older. You still think you’ve still got that same constitution as you had when you were young but it will make me … because I’m a wee bit, let’s say, you know, I’m a bit kind of slapdash with things, that is, like, keeping temperature but it will make me think about it more carefully in future and I think that’s education, and I’m quite aware of the connection” (Group 5, Respondent 6). 

Many believed that the figure 4 and figure 3 statements could be used depending on the audience and situation. Nevertheless, one participant did not believe the statements to be educational, with others disagreeing with the statement suggesting that the statement was educational and necessary: 

“Unfortunately, all I can see is that you’re going to scare people. Whatever you want to do, its scaring people, they’re just going to go, what?” (Group 5, Respondent 7). 

“It’s the education that’s necessary.” (Group 5, Respondent 6). 

Eighteen participants signed-up as individuals who support a person over 65 with their food shopping and cooking, nevertheless some of the individuals who signed up to participate as individuals over the age of 65 themselves, also provided food support for relatives or had done so until recently and were able to reflect on their experiences.

The freezer was frequently referred to by informal caregivers as enabling them to batch cook for those, they care for to ensure they would be able to have a hot meal. Potential food safety risks appear different, with many saying that those they support would no longer be cooking a large piece of meat or a whole chicken, instead buying ready-cooked chicken portions and adding them to a sauce, discussions suggested an increased reliance on ready-to-eat and ready-to-heat foods among this group for convenience for both parties.

Another potential food safety risk may exist as relatives could say their parents’ appetites had declined and were eating much smaller portions, this resulted in the prolonged storage of food, and for those that were widowed relatives described the widowers not adapting to shopping and cooking for one which also resulted in prolonged storage, repeated food consumption and a lack of variety in the diet.

Caring for a relative and providing food related support had a huge impact on the informal caregivers, many of whom had their own families and full-time jobs. It was a change to support parents to maintain their independence and interest in food shopping and cooking, ensuring a good diet and not over-stepping. The change in relationship and family dynamics is a challenging one for people to adapt to. Many relatives described the compromise between the quantity and quality of calories, as much as they wanted their relatives to consume a healthy nutritious diet, this was not always possible due to the desires of the person they support, often this compromise was discussed and was something relatives had to stop worrying about.

Participant 053, who supports her mum with food provision described: “It's like getting that role reversal.”

Table 15 summarises some of the comments shared about the impact of being responsible for the provision of food for relatives over the age of 65 years. These sentiments reflect a broader understanding among family caregivers that their relatives are not only more susceptible to illness but that the consequences of such illnesses could be significantly more severe due to age-related frailty or pre-existing health conditions. This heightened perception of risk integrates two critical components of the health belief model: perceived susceptibility and perceived severity. Caregivers recognize both the likelihood of their relatives contracting an illness, particularly one related to food safety, and the potentially severe outcomes due to their loved ones’ vulnerable health status.

In this way, family caregivers’ views on foodborne illness are shaped by a keen awareness of the potential harm that such an illness could cause, emphasising the critical role that health status and physical resilience play in shaping perceptions of risk. Their concerns are not merely about the possibility of illness, but rather the potentially devastating consequences such an event could have on individuals whose bodies are already compromised, reinforcing the need for careful food safety practices in caregiving environments.

These findings indicate the importance of ensuring any future food safety information resources are also appealing, accessible and useful for family- caregivers who support a person over the age of 65 with food related practices.